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  • Why We Need Anesthesia Providers, Not Robots Or RNs, in GI Settings



    Re: “Use, Cost of Anesthesia for Endoscopy Increasing,” by Monica J. Smith. Gastroenterology & Endoscopy News, May 2012;63:1,26-27.


    Kim Riviello, DNP, MBA/HCM, CRNA


    President, Anesthesia Services Group
    Tipp City, Ohio

    As a certified nurse anesthetist (CRNA), I am horrified at the thought that we could have robots pushing potentially lethal medications. Oh, yes—it is going to be used on healthy patients. I forgot.


    Our population is growing older and sicker. I just completed my dissertation on this topic, in which I reviewed 3,200 charts and proved that there is a definite trend in increased comorbidities in patients being seen not only in gastroenterology settings but also ambulatory surgery centers (ASCs). The following is a brief excerpt from my dissertation, which has been edited for publication in Gastroenterology &

    Endoscopy News:

    A Retrospective Study of a Gastroenterology Facility: Are the Patients Sicker?


    There has been substantial growth in the number of ASCs across the United States. With the advancement in technology for noninvasive procedures and shorter-acting anesthetics, more patients are being seen in freestanding surgery facilities. However, the trend in patient comorbidities (e.g., obesity, diabetes, cardiac respiratory diseases) also has risen, increasing the risk for an anesthesia-related event, even when low-risk procedures are performed. The most common malpractice claims have been associated with diagnostic procedures performed in ASCs under monitored anesthesia care (MAC) with patient comorbidities as contributing factors. The morbidity and mortality of ambulatory surgery patients has led to an increased concern for patient safety in freestanding facilities. Of particular concern is sedation, specifically in gastroenterology (GI) centers. Yet, the Journal of the American Medical Association recently reported that two-thirds of the anesthesia procedures provided during colonoscopies and esophagogastroduodenoscopies (EGDs) were on “low-risk patients,” suggesting a lack of need for professionally administered anesthesia in GI facilities and implying that specialist-monitored anesthesia would contribute to the increased cost of these procedures (Liu H et al. JAMA 2012;307:1178-1184). This study is a retrospective chart review of 3,252 patients, conducted at a GI center over a 10-month period in 2011. The patients’ ages ranged from 18 to 95 years. Procedures involved were either an EGD and/or a colonoscopy with MAC. The preoperative assessment and anesthesia record was used to gather information on each patient. A data analysis table was developed to log comorbidities on a monthly basis (total number and percentages). The comorbidities of the MAC patients were correlated with the American Society of Anesthesiologists (ASA) physical classification system to stratify patients based on disease entities. These data were then compared to provide evidence of an increased trend in the percentage of high-risk patients and associated morbidity and mortality.


    In 1983, there were approximately 239 freestanding surgery facilities in the United States (Durant G. Medical Group Management Journal 1989;36:16-18,20). By 2003, there were more than 3,300 (Casalino LP et al. Health Aff2003;22:56-67; Winter A. Health Aff 2003;22:68-75) and by 2010, the number increased by 61% to 5,316 (“ASC Services,” 2012).


    The U.S. Department of Health and Human Services conducted a study in 2006, to determine the number of surgical and nonsurgical (diagnostic) procedures performed in outpatient settings and freestanding surgery facilities. They collected the data using the 2006 National Survey of Ambulatory Surgery. The sample was composed of 398 freestanding surgery facilities; 295 (74.1%) responded to the survey.
    The National Survey of Ambulatory Surgery estimated that 53.3 million surgical and nonsurgical (diagnostic) procedures were performed in ASCs, with 14.9 million occurring in freestanding surgery facilities. The most frequently performed procedures were colonoscopies (5.7 million), upper endoscopies (3.5 million), extraction of lens (3.1 million) and insertion of prosthetic lens (2.6 million). General anesthesia was performed in 30.7% of freestanding surgery facilities, with greater than 20.8% providing MAC (Cullen KA et al. National Health Statistics Reports Number 11. Revised. Hyattsville, MD: National Center for Health Statistics: 2009). The Medicare Payment Advisor Commission reported that in 2010, 3.3 million Medicare beneficiaries were seen in freestanding surgery facilities (“ASC Services,” 2012).
    Metzner et al performed a closed claims analysis in areas outside hospital operating rooms (ORs), but within the hospital setting, to determine the risk associated with anesthesia being performed in these remote locations (Curr Opin Anaesthesiol 2009,22:502-508). They thought that even though the procedures were relatively noninvasive, serious outcomes could occur. They analyzed claims in the ASA Closed Claims database (1990-1999), comparing injuries associated with care in remote sites (n=87) and hospital ORs (n=3,286). Patients in remote locations were more than 70 years old (>20%), sicker (69%; ASA status 3-5) and underwent more emergent procedures (36%), compared with patients in hospital settings. The predominant anesthetic in these locations was MAC, which resulted in eightfold more claims compared with OR procedures (50% vs. 6%, respectively). The locations most commonly involved in claims were GI suites (32%) and cardiac catheterization laboratories (25%). The severity of injury was greater in remote locations than in ORs, with mortality almost doubled. Adverse respiratory events, oxygen/ventilation being the most common, occurred in both remote and OR locations, but remote locations had sevenfold greater occurrences. Respiratory depression caused by oversedation and loss of airway was responsible for 26 remote-location claims; more than half occurred in the endoscopy suite. Patient factors contributing to oversedation and loss of airway were obesity, sleep apnea, ASA status 3 to 4 and age greater than 70 years.


    In February 2006, a closed claims analysis of cases with MAC found that patients who were older (>70 years) and sicker (ASA status 3-4) had more claims associated with morbidity and mortality (40%; Bhananker SM et al. Anesthesiology2006;104:228-234). Bishop et al also examined malpractice claims, comparing outpatient (freestanding and hospital-based) and OR procedures from 2005 to 2009 (JAMA 2011;305:2427-2431). In the outpatient setting, the most common claim was diagnostic procedures under MAC (45.9%).


    The ASA scoring system is a valuable tool in evidence-based anesthesia practice, helping to determine intraoperative and postoperative complications for patients based on their overall health status. It is also valuable in ascertaining quality outcome measures and patient safety indicators based on comorbidities. Tracking of risk indicators in hospitals has been an important tool to improve quality of patient safety and is now an incentivized program for hospitals (Centers for Medicare & Medicaid Services, “Hospital Initiatives,” 2011). However, this has not occurred in freestanding surgery facilities. A 2009 study surveyed diagnosis-based risk adjustment for surgical and procedural outcomes in ASCs. Seven-day mortality rates for hospital-based outpatient surgery and freestanding facilities were examined. The study revealed that hospital-based outpatient surgery centers reported comorbidities more frequently than freestanding facilities: 59.6% versus 8.7%, respectively, in cataract patients and 90% versus 45%, respectively, in GI patients (Chukmaitov AS et al.Health Care Manag Sci 2009;12:420-433). The requirement for these data from freestanding facilities could be a valuable tool in determining the future morbidity and mortality of patients being seen in these facilities. Studies have demonstrated that freestanding facilities have definitive risks associated with patient comorbidities and the type of anesthesia provided, with diagnostic centers and endoscopy centers providing MAC sedation having the most associated claims.


    Yet, in the 2006 National Survey of Ambulatory Surgery data, there was no information on the comorbidities of the 14.9 million people seen in freestanding facilities and the risk associated with anesthesia. The National Survey of Ambulatory Surgery report stated that procedures in freestanding facilities and outpatient hospital-based facilities increased by 300% over a 10-year period. If this trend continues, by 2016, 44.7 million people will be seen in freestanding facilities. Six million will be older than 65 years and undergoing gastrointestinal procedures (Cullen KA et al. National Health Statistics Reports Number 11. Revised. Hyattsville, MD: National Center for Health Statistics; 2009). In this study, more than 50% of the patient population seeking GI procedures were between the ages of 51 and 70 years. Comorbidities most frequently observed were hypertension, hyperlipidemia, sleep apnea, gastroesophageal reflux disease, diabetes, smoking, coronary artery disease and chronic obstructive pulmonary disease; these comorbidities increased over time, and the increase was statistically significant. Body mass index did not change over time in a statistically significant manner. ASA status 3 cases increased over the study period; changes in ASA status 2 cases were not significant, and ASA status 1 represented only 2.58% of cases.


    Liu et al reported that 66% of anesthesia administered in GI facilities is to “low-risk” patients (JAMA 2012;307:1178-1184). They found that the combination of ASA 1 and 2 cases represented 43.5% of patients receiving anesthesia. Studies have shown that the higher the ASA classification, the greater the odds ratio for developing a postoperative complication. Mortality rates have been reported to be 0.3% to 1.4% for ASA 2, 1.8% to 5.4% for ASA 3, and 7.8% to 25.9% for ASA 4 (Wolters U et al. Br J Anaesth 1996;77:217-222). In a more recent study, Bishop et al reported that major injury and death occurred in the outpatient setting 36.1% and 30.6% of the time, respectively (JAMA 2011;305:2427-2431). As the number of ASA 3 patients seen in freestanding facilities continues to increase over time, are the risks associated with these patients acceptable? Unfortunately, as the study indicates, this is the trend in our society, with the largest generation now aged between 50 and 75 years. The safety of these patients is determined by comorbidities and the assessment performed by the anesthesia clinician and the consultants they deem necessary to determine what is best for each patient. The ASA classification system is subjective in classifying patient risks; however, the anesthesia professional is trained to make this determination with the patient’s safety in mind.


    With the continued increase in demand for freestanding facilities, analysis and documentation of patient comorbidities should be tracked to gain a better understanding of the type of patients being seen in these isolated locations and how to address associated patient safety issues. Administrators and federal and state agencies need to be aware of the level of risk associated with these diseases to ensure that the proper clinician is determining which patients are or are not at risk from a procedure. Bishop et al suggested that because of the high percentage of claims linked to diagnostic procedures with MAC anesthesia, safety initiatives should be developed focusing on the outpatient setting (JAMA 2011;305:2427-2431).



    Chukmaitov et al recommended that federal and state agencies mandate hospital-based outpatient surgery centers and freestanding facilities to provide comprehensive information on all patients related to comorbidities to help determine patient safety guidelines and risk-adjustment measures (Health Care Manag Sci 2009;12:420-433). A performance measure recommended by the Medicare Payment Advisory Commission states that incentives should not discourage providers from accepting riskier or more complex patients, yet the outcome measures that they encouraged the Centers for Medicare & Medicaid Services to incorporate for ASCs do not require any risk adjustment. Patient falls and burns, and wrong site, wrong side, wrong patient, wrong procedure, and wrong implant procedures, as well as hospital transfer/admission errors and surgical site infections are all preventable outcome measurements and are not affected by a patient’s health status (“ASC Services,” 2012). Quantifying patient comorbidities and ASA classifications, as exemplified in this study, would help evaluate risk adjustments as the acuity of the patient population increases. The advantage of having anesthesia during GI cases has been demonstrated through preoperative screening, intraprocedural safety and postoperative satisfaction (Hass W. AnesthesiaReviews Blog, 2013; www.physynergy.com/​blog-anesthesia-services/​bid/​143340/​Anesthesia-Services-Should-Be-Used-For-GI-Endoscopy). This study revealed that most of the patients receiving anesthesia were classified as ASA 3.

    So, is cost still an issue, knowing that the majority of the patients are sick? According to Lui et al, by advocating patient safety, anesthesia is helping to decrease the cost of health care by decreasing intraoperative and postoperative complications (JAMA 2012;307:1178-1184). Hass found that examining cost and procedural factors alone only represents a hindrance to anesthesia; it is through a comprehensive analysis of patient assessments that the societal advantages of patient safety and satisfaction can be found (AnesthesiaReviews Blog, 2013; www.physynergy.com/​blog-anesthesia-services/​bid/​143340/​Anesthesia-Services-Should-Be-Used-For-GI-Endoscopy). Anesthesia intervention is pivotal in freestanding facilities, including GI centers, to ensure proper evaluation of patient comorbidities and risk factors, ascertaining the appropriate anesthetics are administered, and patients remain safe.


    Regardless of the practice environment, patients should be assured that they are receiving a safe and quality anesthetic from an anesthesia professional.



    Found HERE
    Comments 1 Comment
    1. captgaston's Avatar
      captgaston -
      As these lawsuits build, our case with strengthen. Just concerned for the ignorant patients who will suffer...
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